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ENT OSCE Review by KP Ferraris Outline • 10-pt identification quiz • Case presentations with quiz – Case 1 – Case 2 – Case 3 • Other ENT symptoms • Laundry list of must-know and common diagnoses (For best resolution, view this as Slide Show.) Outline • 10-pt identification quiz • Case presentations with quiz – Case 1 – Case 2 – Case 3 • Other ENT symptoms • Laundry list of must-know and common diagnoses Identification Quiz 1. Shown below is a Lateral X-Ray of the neck showing the thumbprint sign. What is the most likely diagnosis? a. b. c. d. Retropharyngeal abscess Epiglottitis Acute Tonsillopharyngitis Croup Answer: b. Epiglottitis (double t in the first only). It is characterized by fever, drooling, dysphagia, odynophagia, noisy breathing, stridor Identification Quiz 2. Identify the lesion/diagnosis. The larger field is oral mucosa. Answer: Aphthous ulcer or Aphthous stomatitis. It is an erosion of the mucosa caused by either trauma, hot foods/liquid, or lack of hygiene. Identification Quiz 3. Give the complete diagnosis, with Grading. Answer: Tonsillitis Grade III with Peritonsillar Abscesses (Quinsy). The usual complaint is odynophagia and dysphagia, with or without fever. Identification Quiz 4. What type of fracture is shown? a. b. c. d. e. Le Fort I Le Fort II Le Fort III Tripod Temporal bone Answer: b. Le Fort II fracture. In contradistinction to Le Fort I which is only in the maxilla (upper jaw) and Le Fort III which involves the inferolateral portion of the orbit (cheek). Identification Quiz 5. Identify this diagnostic test used to confirm Benign Paroxysmal Positional Vertigo (BPPV). Answer: Dix-Hallpike test. It is confirmatory for only one pathology: BPPV, a disorder of the posterior semicircular canal. If positive, where the head is turned to is the side of the lesion. Identification Quiz 6. Classify the cleft lip and palate using the Thallwitz nomenclature. Answer: L3 A3 H3 S3 H3 A3 L3 (Remember from RIGHT to LEFT, and only one S). Mnemonic is “Lahshal.” This is surgically corrected by Cheiloalveolorhinoplasty. Identification Quiz 7. Which is the most important part of the sinonasal anatomy commonly blocked during Sinusitis? Answer: Ostiomeatal Unit. It is the common drainage of all sinuses EXCEPT 2: posterior ethmoid cells and the sphenoid sinus. Identification Quiz 8. What is the most common etiologic agent (bacteria) of Otitis Media? Answer: Streptococcus pneumoniae. H. influenzae is more common in pedia. Another agent is M. catarrhalis. Identification Quiz 9. Below is a picture from posterior rhinoscopy. It is the potential site of growth for Nasopharyngeal carcinoma. a. b. c. d. Vallecula Rosenmüller’s fossa Pyriform sinus Choana Answer: b. Rosenmüller’s fossa. It is a pharyngeal recess (bilateral) at the back of the nose (nasopharynx) near the torus tobarius surrounding the entrance to the Eustachian tube. Identification Quiz 10. Interpret the Audiogram below. Answer: Sensorineural hearing loss, mild, AD. See next slide for explanations. AD means right ear (cf. AS, left ear) Audiogram Meaning Right ear Left ear Air unmasked O X Air masked ∆ Bone unmasked < > Bone masked [ ] Remember: Air (AC) uses shapes and X, Bone (BC) uses [ ] and greater-than less-than. Audiogram Conductive hearing loss Sensorineural hearing loss Mixed hearing loss BC is normal while AC is >25 dB. In sensorineural, both AC and BC are >25 dB. But BC dipped in higher freq. Similar to sensorineural, both AC and BC are >25 dB in mixed. But both AC and BC really dip together. Result Normal Conductive hearing loss Sensorineural hearing loss Mixed hearing loss AC <25 dB >25 dB >25 dB >25 dB BC <25 dB <25 dB >25 dB >25 dB Outline • 10-pt identification quiz • Case presentations with quiz – Case 1.0, 1.1, 1.2, 1.3, 1.4 – Case 2 – Case 3 • Other ENT symptoms • Laundry list of must-know and common diagnoses Case 1.0 A.Y., a 19 year-old male complained of otalgia. What questions about the history will you ask? Hx: OPQRST of Pain, Colds? Allergies? Rode airplane/diving/swimming? Discharge (Otorrhea)? Fever? Hearing loss? Dizziness? Headache? What will you perform on P.E.? Inspect for craniofacial anomalies, Otoscopy, Anterior rhinoscopy, Posterior rhinoscopy/Nasal endoscopy, Weber test, Rinne test, Schwabach test (due to the hearing loss) and complete HEENT exam (because may be Referred only). Case 1.0 Hx revealed: 2 years PTC: recurrent otorrhea Sought consult, prescribed w/ unrecalled meds (oral and topical drops), doctor said that tympanic membrane was intact. 1 year PTC: otalgia and otorrhea worsened; consult revealed perforated tympanic membrane. 2 weeks PTC: low-grade fever, headache localized to temporal bone, dizziness, persistent otalgia and otorrhea Case 1.0 You took your Welch Allyn and Otoscopy revealed: How would you describe the otoscopic findings? Review of Otoscopy It is important to memorize the anatomic parts of the tympanic membrane to be able to say where the perforation is, where hyperemia is, where the keratin debris are, or where the serosanguinous fluid is coming out. The cone of light reflex (from the reflection of the otoscope light) always points anterior. So this is the RIGHT ear. Case 1.0 How would you describe the otoscopic findings? Perforation at the pars flaccida, 30% Serosanguinous fluid behind the TM (discoloration) Hyperemia in the Epitympanum Case 1.0 A.Y., a 19 year-old male complained of otalgia. What other diagnostic tests will you request? Pure Tone Audiometry, Audiogram, and Imaging: CT-scan or MRI? MRI would be good for soft tissues but not for this case. CT would be better because it assesses bony integrity which will confirm concomitant complications such as: Skull-base Osteomyelitis or Petrositis Acute Mastoiditis Coalescent Mastoiditis Besides, CT will better aid future surgical interventions. Presence of erosion of the labyrinth at the left ear (axial cut). Although a CT scan usually cannot make a definitive diagnosis regarding the nature of any existing temporal bone disease, the presence of labyrinthine erosion is highly-suggestive of Cholesteatoma. Opacification of the mastoid antrum and mastoid air cells at the left ear (axial cut). This finding is suggestive of Coalescent Mastoiditis, and other sequelae of worse prognosis such as subperiosteal abscess and intracranial complications. Case 1.0 You requested CT and findings revealed: How would you describe the CT findings? Case 1.0 Audiogram revealed: Conductive hearing loss, mild, both ears. Average hearing level is approximately 35 dB. How would you interpret? Review of Weber test Normal Unilateral conductive hearing loss Unilateral sensorineural hearing loss Lateralization Midline, sound equally heard Sound lateralizes to poor ear Sound lateralizes to better ear What results of the Weber test would you expect in a patient with mild conductive hearing loss on the left and normal right ear? Lateralize to right or left? Review of Rinne test Normal or sensorinueral hearing loss(+) Unilateral conductive hearing loss (-) Result AC >BC (positive) BC>AC (negative) What results of the Rinne test would you expect in a patient with mild conductive hearing loss on the left? AC > BC or BC > AC? Back to Case 1.0 What is the diagnosis? Otitis Media with Effusion (OME) Chronic Otitis Media (COM) without Cholesteatoma COM with Cholesteatoma; Coalescent Mastoiditis*; R/O Labyrinthine Fistula** 2 years PTC: recurrent otorrhea Sought consult, prescribed w/ unrecalled meds (oral and topical drops), doctor said that tympanic membrane was intact. 1 year PTC: otalgia and otorrhea worsened; consult revealed perforated tympanic membrane. Correlate with Otoscopy. 2 weeks PTC: low-grade fever, headache localized to temporal bone, dizziness, persistent otalgia and otorrhea; Correlate with Otoscopy and CT findings. *Acute Mastoiditis already accompanies COM without Cholesteatoma but Coalescent Mastoiditis is the one that causes fever and CT-findings. Furthermore COM can be Suppurative if the discharge is purulent or pus-like. **Labyrinthine Fistula must be ruled-out due to the dizziness. If the dizziness is characterized to be vertigo, then there is inner ear involvement, making this a concomitant diagnosis. Case 1.0 A.Y., a 19 year-old male complained of otalgia. The diagnosis of Chronic Otitis Media with Cholesteatoma; Coalescent Mastoiditis, left ear requires further investigation as to its cause. Did the patient have failed treatment from previous ear infection (e.g. after swimming)? Does the patient have craniofacial abnormalities (e.g. cleft palate, deformed ear) that make him prone to Eustachian tube dysfunction and ear canal dysfunction respectively? Does the patient complain of “sneezing everyday, especially upon waking up,” such that it interferes with daily activities? Case 1.1 You can have Cholesteatoma without having Otitis Media! This diagnosis is: Attic Retraction Cholesteatoma. From trans: CC: 5 year history of on/off right ear with gradual hearing loss. No otorrhea. Figure below. Normally, extension of the blood vessels on the ear canal are travel in a radial fashion towards the ear drum and then to the head of malleus (or umbo). Recall that Cholesteatoma is skin/keratin debris that eroded portions of the ear. Abnormal: what if a part of the eardrum gets sucked in attic retraction You will see an interruption in the path of the blood vessel. Then you will see the blood vessel reappear. The blood vessel “stops” in its path because it traversed a weak part – the part that gets sucked in by negative pressure A part of the eardrum gets sucked in but the rest of it remains in place. Therefore, the eardum would look ballooned out. The part of the eardrum sucked in is made of skin and this will keep on producing new skin (cholesteatoma) leads to invagination eventually eroding the ossicle and the promontory Most likely diagnosis is Acute Otitis Externa, R/O concomitant Acute Otitis Media. Since otalgia is also a characteristic of Otitis Media (OM) and because the tympanic membrane is not seen, OM cannot be fully ruled-out. Because the patient has a history of swimming, and because the Otitis Externa (OE) is diffuse, this is most likely caused by Pseudomonas aeruginosa. In contrast to S. aureus where it is more likely due to ear manipulation and the OE is circumscribed, not diffuse. Case 1.2 WHAT IF our patient A.Y., a 19 year-old male, complained of otalgia, without otorrhea. No other symptoms. Hx revealed swimming in Montalban river 2 days PTC. Otoscopy revealed: Here, external auditory canal is narrowed, precluding visualization of the tympanic membrane. What is the most likely diagnosis? Since this looks like infection, what is the most likely etiologic agent? Case 1.3 WHAT IF our patient A.Y., a 19 year-old male, complained of otalgia, with otorrhea, with other symptoms of difficulty breathing in the nose and frequent sneezing. Hx revealed 3 yrs PTC: recurrent bilateral watery rhinorrhea associated with hyposmia, frontal headache 1 yr PTC: symptoms progressed, now with total nasal obstruction on the left, mucopurulent nasal discharge bilateral and post-nasal drip, anosmia, hyponasal speech and left sided facial pain. Otoscopy is the same as Case 1.0 Case 1.3 Anterior rhinoscopy of the left nares: (+) smooth, gelatinous, semi-translucent and pale white mass arising from the pink mucosa What other P.E. will you do? Anterior rhinoscopy to visualize the inferior turbinate and meatus and the anterior portion of the middle turbinate. Anterior rhinoscopy revealed: Anterior rhinoscopy of the right nares: mucosal edema, swollen and hyperemic nasal septum and middle turbinate; (+) of obstructive mass, visualization of which is precluded by a suppurative yellow discharge Looks familiar… Nose SGD! Case 1.3 What other diagnostic tests will you request? CT-scan or MRI? MRI would be good for soft tissues but not for this case. CT would be better. CT scan of the what? What view? a. b. c. d. Axial Coronal Waters Transverse a. Temporal bone b. Sinuses c. Orbit and facial bones d. Nasopharynx See next slide for answer. Left: complete opacification of the maxillary sinus and Ostiomeatal unit (OMU); partial opacification of the anterior ethmoid cells with air-fluid level Right: complete opacification of the anterior ethmoid cells and OMU; partial opacification of the maxillary sinus with airfluid level Overall: Homogeneity of opacification; intact bony structures with (–) bone remodeling or thickening Case 1.3 You requested CT (coronal view) of the sinuses and findings revealed: Diffuse mucosal thickening whether partial or complete suggests mucosal hypertrophy from inflammation, retained secretions and obstruction, as well as polyposis. Opacification of the OMU is indicative of grave obstruction because it will eventually involve almost all of the paranasal sinuses. How would you describe the CT findings? Case 1.3 RECAP: A.Y., a 19 year-old male, complained of otalgia, with otorrhea, with other symptoms of difficulty breathing in the nose and frequent sneezing. What is the diagnosis? The diagnosis is: Chronic Rhinosinusitis (Pansinusitis); Inflammatory Nasal Polyposis with concomitant Chronic Otitis Media with Cholesteatoma and Coalescent Mastoiditis Case 1.4 WHAT IF our patient A.Y., a 19 year-old male, complained of otalgia, without otorrhea. No other symptoms. Hx revealed sensation of swelling “inside ear” Otoscopy cannot be done due to microtia and absence of external meatus. Case 1.4 You requested CT (coronal view) of the temporal bone and findings revealed: How would you describe the CT findings? A big mass of skin has eroded the bone. Case 1.4 RECAP: A.Y., a 19 year-old male, complained of otalgia, without otorrhea. No other symptoms. Microtia and absence of external meatus. What is the diagnosis? The diagnosis is: External Canal Cholesteatoma secondary to Congenital Meatal Stenosis. From trans: •pain and swelling behind ear •Granulation tissue present •Ear with an abnormal pinna; 2 mm ear canal •Grayish mass of soft tissue with some blood inside the ear canal •In congenital meatal stenosis, the outer part of the ear canal is narrow but the inner part is not as narrow. Since the canal’s skin is like a conveyor belt, the skin gets dammed back inside because the outer opening is so narrow, causing skin extension to the middle ear and possibly, to the bone. Pus may drain from the ear (posteriorly). General Principles of Treatment For Otitis Externa: Topical antibiotic drops: Ciprofloxacin, Ofloxacin; but fluoroquinolones for Pseudomonas For Otomycosis: Topical antifungal drops: Miconazole, Ketoconazole For Otitis Media: Systemic antibiotics, esp. if with fever +/analgesics For Impending Perforation of tympanic membrane: Myringotomy, and tube; antibiotics For Cholesteatoma, with Mastoid involvement and Perforation: Surgery (Tympanoplasty, Mastoidectomy) Outline • 10-pt identification quiz • Case presentations with quiz – Case 1 – Case 2.0, 2.1, 2.2, 2.3, 2.4 – Case 3 • Other ENT symptoms • Laundry list of must-know and common diagnoses Case 2.0 O.T., a 39 year-old female complained of hoarseness. What questions about the history will you ask? Hx: Quality of hoarseness? Duration of hoarseness? Progressive? Pain? OPQRST of Pain, Cough and colds? Sore throat? Occupation? What will you perform on P.E.? Inspection of oral cavity, and complete HEENT exam (because there might be associated s/sx). Case 2.0 Hx revealed: 1 week PTC: hoarseness, non-progressive; no dysphagia, cough, colds; patient was previously normal Occupation: singer (alto); Noticed that hoarseness worsened with reaching the high notes of soprano Case 2.0 O.T., a 39 year-old female complained of hoarseness. What diagnostic test will you request? Best answer: Laryngoscopy, a.k.a. Stroboscopy or Strobovideo laryngoscopy Other tests could be: •Objective voice assessment (not elaborated in lecture) •Laryngeal electromyography (not elaborated) •High-resolution CT of the larynx Imaging such as CT are not really of use in this case. However, imaging may be important: • if the patient complains of dysphagia • if the doctor is entertaining malignancy Laryngoscopy revealed: Case 2.0 What is the diagnosis? Laryngoscopy revealed: Subepithelial hemorrhage. From trans: •Often results from voice abuse or misuse •Voice rest usually resolves hemorrhages, with restoration of normal voice •In rare cases, the hemorrhage organizes and fibroses, leading to scarring •In specially selected cases, surgical incision and drainage of the hematoma may be done Treatment: •Absolute voice rest until the hemorrhage has resolved (usually about 1 week) •Relative voice rest until normal vascular and mucosal integrity have been restored (usually about 6 weeks) •Recurrent vocal fold hemorrhages are usually due to weakness in a specific blood vessel, which may require surgical cauterization of the blood vessel using a laser or microscopic resection of the vessel Case 2.1 WHAT IF our patient O.T., a 39 year-old female, is a teacher; complained of nonprogressive hoarseness which started 6 months ago. Fatigable voice after 1-hour of speaking. Laryngoscopy revealed: What is the diagnosis? The diagnosis is: Benign vocal cord nodules. •Callous-like masses of the vocal folds caused by vocally abusive behavior •Hoarseness, breathiness, loss of range and vocal fatigue •Voice abuse should be suspected particularly in patients who report voice fatigue associated with voice use, in those whose voices are worse at the end of a working day or week, and in those who are chronically hoarse •Confined to the superficial layer of the lamina propria •Composed primarily of edematous tissue or collagenous fibers •Vocal nodules are bilateral and fairly symmetrical •mid membranous portion: area with most contact •Treatment: oVoice therapy 6-12 weeks oIn rare cases, may need microsurgical excision Bilateral, midline protrusions Case 2.2 WHAT IF our patient O.T., a 39 year-old female, is a teacher; complained of nonprogressive hoarseness which was there for as long as she can remember. Laryngoscopy revealed: What is the diagnosis? The diagnosis is: Submucosal cyst. •May arise from a blocked mucus gland duct, but may also be congenital •Often mistaken for nodules •Often cause contact swelling to the contralateral cord •Diagnosis: o Fluid-filled appearance on strobovideolaryngoscopy o Lined with thin squamous epithelium; Retention cysts contain mucus; o Epidermoid cysts contain caseous material o Located in the superficial layer of the lamina propria. In some cases, cysts are attached to the vocal ligament. •Treatment: oVoice therapy does not resolve the cysts oMicrosurgical exclusion Unilateral, midline protrusion Case 2.3 WHAT IF our patient O.T., a 39 year-old female, is a teacher; smoker (5 pack-years); complained of non-progressive hoarseness for 1 month. She has a low, coarse, gruff voice which makes her voice mistaken as a male’s. What is the diagnosis? The diagnosis is: Laryngoscopy revealed: Reinke’s edema. •Low, coarse, gruff voice •Often associated with smoking, voice abuse, reflux, and hypothyroidism •Diagnosis: o "elephant ear" floppy vocal fold appearance o the superficial layer of lamina propria (Reinke's space) becomes edematous •Treatment: oTreat underlying condition oOften requires surgery, which is generally done one side at a time Bilateral, fluidfilled protrusions at the base Case 2.4 WHAT IF our patient O.T., a 39 year-old female, is a sales agent; smoker (20 packyears); complained of progressivelyLaryngoscopy revealed: worsening hoarseness for 2 years. She has Anterior a low, coarse, gruff voice which makes her voice mistaken as a male’s. Relevant P.E. showed palpable lymphadenopathy (non-tender) of the Left Right submental and (right) submandibular triangles, Level I, IIA, and IIB. Inspection of the oral cavity revealed a 4x4cm painless lump in the underside of the tongue. Unilateral, hemorrhagic mass What is the diagnosis? (metal is an endotracheal tube) The diagnosis is: Squamous cell carcinoma of the larynx and floor of the mouth. •May present as an exophytic, or infiltrative lesion •Smoking, alcohol intake are risk factors •Voice problems may be an early symptom of laryngeal cancer •Can be treated with radiotherapy, surgery, chemotherapy, or a combination of the three Outline • 10-pt identification quiz • Case presentations with quiz – Case 1 – Case 2 – Case 3.0 • Other ENT symptoms • Laundry list of must-know and common diagnoses Case 3.0 B.L., a 22 year-old male sought consult for his unilateral neck mass, right since 8 months ago. Nb: This is based on a true patient during ENT ClinEx in Amang last Oct. 21, 2011; with slight modification only of the chief complaint and a PE result. Case 3.0 O.T., a 22 year-old male sought consult for his unilateral neck mass, right since 8 months ago. What questions about the history will you ask? Hx: Progressive enlargement? Headaches? Cough and colds? Sore throat? Mumps, Parotitis, Otitis? Pain? Nasal obstruction? Rhinorrhea? Epistaxis? Otalgia? Otorrhea? Hearing loss? Tinnitus? Dysphagia? Hoarseness? Trismus? Limitation of jaw movement and mouth opening? Occupation? What will you perform on P.E.? Complete HEENT exam including Cranial nerve exam. Case 3.0 O.T., a 22 year-old male sought consult for his unilateral neck mass, right since 8 months ago. History revealed: The patient claimed to be previously normal; (–) infectious/inflammatory diseases such as mumps, parotitis, otitis. 8 months PTC: first noticed a small lump, non-movable, non-tender, at the right lateral neck (4x4cm), inferior to the ear and posterior to the jaw. 7 months PTC: tinnitus, described as “offline of TV station,” persisted until consult; “mabigat ang kanang tenga” 6 months PTC: neck mass swelled twice the size 5 months PTC: limitation in fully opening the mouth and trismus at the right; diminished hearing at the right (40%) 4 months PTC: one episode of epistaxis, 5mL blood, relieved by cold compress 3 months PTC: earache at the right ROS: recurrent headaches; snoring Case 3.0 O.T., a 22 year-old male sought consult for his unilateral neck mass, right since 8 months ago. History revealed that the mass enlarged up to the size shown below: Review of the Relevant Levels and Triangles of the Neck See next 3 slides! Back to Case 3.0 O.T., a 22 year-old male sought consult for his unilateral neck mass, right since 8 months ago. P.E. revealed: (–) weight loss; afebrile Anterior rhinoscopy: essentially unremarkable – no polyps, masses, septal deviation, and other lesions Posterior rhinoscopy: (not done) HEENT: normal-bulk masseter and temporalis muscles; nonenlarged and non-tender parotid gland; no facial abnormalities; small lump, slightly-movable, non-tender, at the left lateral neck (1x1.5cm), inferior to the ear and posterior to the jaw (unnoticed by the patient); no palpable lymph nodes Cranial nerve exam: intact corneal reflex, intact sensory and motor for V1, V2, V3 branches, intact motor functions for XI and VII except for weakness of the platysma at the right Weber test: lateralized to the right Rinne test: BC > AC at the right, BC > AC as well at the left Case 3.0 What is the meaning of this? • Weber test: lateralized to the right Which of the following are possible interpretations for Weber? a. b. c. d. e. f. There is conductive hearing loss on the right There is conductive hearing loss on the left There is sensorineural hearing loss on the left There is sensorineural hearing loss on the right A and C B and D Answer: e. A and C. Although both A and C are possible interpretations for lateralization to the right, the patient (case 3.0) might only have conductive hearing loss on the right. Case 3.0 What is the meaning of this? • Rinne test: BC > AC at the right, BC > AC as well at the left Which of the following are possible interpretations for Rinne? a. b. c. d. e. f. There is conductive hearing loss on the right There is conductive hearing loss on the left The left either has sensorineural hearing loss or is normal The right either has sensorineural hearing loss or is normal A and B C and D Answer: e. A and B. In the case of the patient, he notices the diminished hearing only on the left because it is relatively weaker. Remember too that a positive Rinne test (AC > BC) is NORMAL! Case 3.0 With Tintin’s otoscope, Otoscopy revealed: How would you describe the otoscopic findings? Case 3.0 How would you describe the otoscopic findings? Hyperemia in the Pars flaccida Serosanguinous fluid behind the TM (discoloration) Intact tympanic membrane, no perforation; good cone of light reflex Case 3.0 O.T., a 22 year-old male sought consult for his unilateral neck mass, right since 8 months ago. Further P.E. revealed: Oral cavity: numerous dental caries; Grade I Tonsillitis; pink mucosa; midline uvula; no atrophy, fasciculations and other lesions for the tongue; non-enlarged posterior pharyngeal follicles, no other lesions noted; intact gag reflex Case 3.0 O.T., a 22 year-old male sought consult for his unilateral neck mass, right since 8 months ago. What diagnostic tests will you request? All of the following are generally useful for evaluation EXCEPT: a. CT b. Chest X-ray c. Ultrasound d. FNAB e. MRI f. None of the above Answer: f. None of the above because all are useful; CT and MRI are good choices for whole Head & Neck evaluation; CXR would be useful for TB and ruling-out some differentials; FNAB would be useful for minimizing the seeding if the mass were malignant; and UTZ may guide the FNAB, especially if the mass has cystic components. Case 3.0 You requested CXR and readings by the radiologist found Ghon lesions at the apical lung portions. An ENT in Amang did a therapeutic trial by having the patient undergo a 1-month treatment of Izoniazid, Rifampicin, Ethambutol, and Pyrazinamide. The doctor suspected that the neck mass is: due to Tuberculosis presenting as TB Adenitis of the cervival lymph nodes. Nb: This is the actual course of action taken by the ENT and corroborated by Dr. Lacanilao as an appropriate initial management if TB is suspected. However, after 1 month of compliant medication use, the patient’s mass did not subside but actually grew in size. Case 3.0 You requested CT and findings are below: Review of the Relevant Radiologic Anatomy of the Neck See next 2 slides! PMS – Pharyngeal Mucosal Space PPS – Parapharyngeal Space RPS – Retropharyngeal Space PMS – Pharyngeal Mucosal Space PPS – Parapharyngeal Space RPS – Retropharyngeal Space Case 3.0 How would you interpret the CT findings? There is obliteration of the pharyngeal mucosal and parapharyngeal spaces. There is a heterogeneous mass noted on the posterior pharyngeal wall, superior portion. Case 3.0 You may also request MRI (although CT may suffice) and findings are below: Blue arrows point the pharyngeal mass; White arrows point the lateral neck mass. The neck mass has the same homogeneity as the pharyngeal mass. Case 3.0 O.T., a 22 year-old male sought consult for his unilateral neck mass, right since 8 months ago. What is your next diagnostic step for workup? After seeing the imaging results, you choose to do biopsy. Which are the next courses of action? a. Endoscopic biopsy of the nasopharynx b. Fine needle aspiration biopsy (FNAB) of the neck mass c. Either A or B d. Neither A or B Answer: c. Either A or B because the neck mass and the mass in the nasopharynx are connected. Case 3.0 Before doing the biopsy, Posterior rhinoscopy is done. It revealed the picture below. Interpret. There is obliteration of the Rosenmüller’s fossa by a growing space-occupying (mass) lesion. Case 3.0 After all the revealed information from History, PE, Imaging, your Primary impression, even without the biopsy results yet, is: Nasopharyngeal Carcinoma. This accounts for the neck masses because pharyngeal tumors metastasize early. In fact, a neck mass may precede the demonstration of a mass in the nasopharynx (by posterior rhinoscopy). What are other differential diagnoses? • Lymphoma (Non-Hodgkin’s). • Lymphoma (Burkitt’s). • 2nd Branchial Cleft Cyst with superimposed infection. • Rhabdomyosarcoma. Case 3.0 How can we rule-out the other DDx? • Lymphoma (Non-Hodgkin’s and Burkitt’s) Lymphoma (Burkitt’s) frequently present as supraclavicular neck masses and a much faster growth in size (days or weeks). They may also recede in size and grow back again insiduously. Lymphomas are systemic cancers and frequently begin as intrathoracic masses. These are not evident in the patient. • 2nd Branchial Cleft Cyst with superimposed infection; although congenital, they may enlarge rapidly if with superiposed infection. However, the patient denied having a mass prior to the earliest mass presentation; and no fever and constitutional symptoms can suggest superimposed infection. • Rhabdomyosarcoma; although more common in the pediatric population, this presents as a growth of soft tissue mass. However, this cannot account for other head & neck manifestations. General Principles of Treatment For Nasopharyngeal Carcinoma: Radiotherapy For Lymphoma: Chemotherapy For Branchial Cleft Cysts: Surgery Outline • 10-pt identification quiz • Case presentations with quiz – Case 1 – Case 2 – Case 3 • Other ENT symptoms (and Review of the former shown) • Laundry list of must-know and common diagnoses ENT symptoms • Hearing loss (conductive) suggests involvement of either the external ear or middle ear, or both. Dx could be Otitis Externa or Media, Perforated tympanic membrane, or Impacted cerumen. Otomycosis is heralded by pruritus (itch). • Hearing loss (sensorineural) suggests involvement of the inner ear, frequently damage to the cilia and/or the auditory nerve. This is different from mixed hearing loss (both conductive and sensorineural) and also from central hearing loss due to lesions in the auditory cortex. • Tinnitus described as “ringing in the ears” is a very nonspecific symptom that can signify inner ear involvement as well. It can accompany any other head & neck pathology and can be in normal individuals. • Otalgia or earache and Otorrhea or ear discharge can both be from Otitis Externa or Otitis Media. Otorrhea can happen even in an intact tympanic membrane, i.e., if due to Otitis Media with Effusion (OME) or if due to a pus in the external canal. Otalgia can happen in non-infectious cause such as in pressure changes (e.g. riding an airplane). This condition, called Barotrauma, is frequently accompanied by Hemotympanum, or blood inside the tympanic membrane. ENT symptoms • Dizziness is a non-specific symptom that may not be an ENT case. It must be further characterized. TYPES Lightheadedness (lumulutang) CAUSES some drugs, metabolic processes (hypothyroidism, hyperglycemia, hypoglycemia pregnancy) Spinning Induced by vestibular (ear)/ central (umiikot, vertigo) (brain: cerebellum and area of the brain stem) problems, visual system (but in actuality, the eyes are affected by the changes in the ear and not the reverse) Feeling of fainting or cardiac (any cardiac condition, things syncope which decrease blood supply to the (hinihimatay, brain), neurovascular (related to the mawawalan ng blood supply to the brain) malay) Unsteadiness/ alcohol intake, neurologic, Imbalance/ musculoskeletal, proprioceptive loss dysequilibrium (cause: lesions of the posterior (nalulula/ parang column, Syphilis – tabes dorsalis, laseng/ nawawalan peripheral neuropathy – diabetes) ng balanse/natutumba) • Vertigo is connected with dizziness but is characterized by a spinning sensation. It must be differentiated if central (Neuro case) or peripheral (ENT case). ENT symptoms • Vertigo and its differentiation: Table 1. Characteristics of Peripheral and Central Vertigo PERIPHERAL CENTRAL Vertigo Nystagmus Intermittent Severe Always present Unidirectional Never vertical Constant Less Severe May be absent Uni/Bidirectional May be vertical Associated Findings: Often present Rarely present Hearing Absent Typically present loss/tinnitus Intrinsic brainstem signs Table 2. Differences in Nystagmus in Peripheral and Central Vertigo PERIPHERAL CENTRAL Direction Any Laterality Horizontal or horizontorotator y (never vertical) Bilateral Latency Duration Intensity Fatigability Long (>10 sec) Transient (<1 min) Mild to severe Fatigable Short (<10 sec) Sustained (>1 min) Mild Nonfatigable Unilateral or bilateral Visual Fixation Suppressed NOT suppressed (may be Table 3. Dix-Hallpike Test in Peripheral and Central Vertigo enhanced) PERIPHERAL CENTRAL ENT symptoms • Nasal Obstruction and Nasal Congestion go hand-in-hand in that one can cause the other, creating a vicious cycle. For example, Rhinosinusitis can predispose one to Polyps, although the latter can also worsen the former’s symptoms. • Nasal Discharge or Rhinorrhea may be as benign as allergy or as worse as CSF Leak. • Epistaxis or nosebleed is a symptom and not a disease. It can be in normal individuals and can be due to a variety of reasons such as friable blood vessels, and benign and malignant mass lesions. For pedia, it may be a sign of Dengue. • Sore throat is part of the symptom of Dysphonia or Hoarseness, a symptom of laryngeal pathology. Most benign lesions are usually non-progressive unless insult is continuous. Dysphagia or difficulty swallowing and is often due to infectious or inflammatory causes of the oropharynx and hypopharynx. It could also be esophageal in origin. In contrast, Stridor, or wheezing sound, is often due to tracheobronchial problems. • Snoring can accompany Obesity and palatal abnormalities. ENT symptoms • Trismus is the inability to normally open the mouth due to one of many causes. It may be due to maxillofacial fractures. • Most ENT symptoms suggest pathologies confined to the head & neck, except for signs and symptoms arising from the neck and nearby structures. Neck pain can be due to infection in the neck but along with jaw pain, is a frequent sign or referred pain due to Myocardial Infarction. Neck masses can be from head & neck primary but can also be metastases from systemic cancers. Outline • 10-pt identification quiz • Case presentations with quiz – Case 1 – Case 2 – Case 3 • Other ENT symptoms (and Review of the former shown) • Laundry list of must-know and common diagnoses Other common ENT Dx not mentioned previously This list excludes most ear conditions as these have been extensively mentioned elsewhere in the previous slides. Thyroid and Parathyroid diseases will be touched on Endo. • Acute Tonsillopharyngitis • Acute Laryngitis • Papilloma of the larynx • Presbylaryngeus • Laryngopharyngeal reflux • Sulcus Vocalis • Oral Candidiasis • Retropharyngeal Abscess • Foreign body in the nose, throat • Laryngotracheobronchitis • Laryngotracheal Stenosis • Juvenile Angiofibroma • Allergic Rhinitis • Sialolithiasis • Pleomorphic Adenoma Other common ENT Dx not mentioned previously • Vestibular Schwannoma • Presbycussis • Menierre’s disease • Viral Labyrinthitis • Tympanosclerosis • Rhinitis medicamentosa • Atrophic Rhinitis • Vasomotor Rhinitis • Thyroglossal duct cyst • Hemangioma • Nasal bone fracture • Mandibular fracture • Tripod fracture • Zygomatic arch fracture Outline • 10-pt identification quiz • Case presentations with quiz – Case 1 – Case 2 – Case 3 • Other ENT symptoms (and Review of the former shown) • Laundry list of must-know and common diagnoses GOOD LUCK!